Traumatic brain injury (TBI) is the leading killer of children over one year of age. In 2003, the evidence based Guidelines for the Acute Medical Management of Severe Pediatric Traumatic Brain Injury was published. Yet, here are no strategies to increase adherence to these guidelines. Our project goal is to use an adherence scorecard to examine the association between adherence and patient outcomes, develop a value stream map illustrating factors impacting adherence, and use computer simulation to create a best practices blueprint for adherence. The guiding hypothesis is that organizational factors predict, adherence predicts outcomes and that a best practices blueprint will result in both adherence and favorable outcomes after severe pediatric TBI. Specific Aim # 1: To develop a national adherence scorecard that characterizes national variation in adherence to the Pediatric Guidelines, and to use the scorecard to examine the relationship between adherence and patient outcomes. Hypothesis # 1: Data abstracted from charts at 5 pediatric trauma centers and the Healthcare Cost and Utilization Project's (HCUP) child inpatient database (KID) will show that there is unwanted and remediable variability in the degree of adherence to the Pediatric Guidelines. The adherence score card will be used to classify study site adopter status, characterize variability in adherence within and between all sites, and provide large scale Class II evidence that adherence is associated with better outcomes (discharge to home vs. inpatient rehabilitation vs. long term facility or died, and hospital length of stay. Specific Aim # 2: To create a value stream map that readily identifies remediable high priority provider and organizational factors which impact adherence to the Pediatric Guidelines and examine whether these factors vary by adopter status (defined in Aim # 1). Hypothesis # 2: Barriers to adherence are high across adopter categories and constitute both provider and organizational factors. Survey methods and focus groups will show that remediable barrier and facilitator profiles vary by adopter status. Value stream maps will be generated based on the activity flows of TBI care and outcomes identified via chart abstraction (Aim #1), KID data, and survey and focus group outcomes (Aim # 2). Value stream maps will define remediable, and value added TBI care processes by adopter status. Aim # 3: To use computer simulation to develop and disseminate a best practices blueprint for adherence to the Pediatric Guidelines. Hypothesis # 3: Computer simulation models will determine the effect of TBI care processes on key Pediatric Guideline indicators and patient outcomes based on parameter estimates of adherence and effectiveness from regression models (Aim # 1) and activity inputs of value stream maps (Aim # 2). Iterative computer simulation will demonstrate the relationship among Pediatric Guideline components and how relative changes in activities impact the magnitude, direction and choice of operations downstream in TBI care and patient outcomes. These results will then contribute to a best practices blueprint for the adherence by adopter status. Findings will be widely disseminated. Sites to be randomized to examine the effect of the best practices blueprint on adherence to the Pediatric Guidelines and on patient outcomes will be identified.